New legislation missing crucial understanding of treatment

As the former provincial chief psychiatrist of Manitoba, and having specialized in the assessment and treatment of both psychosis and addiction to alcohol, opioids and methamphetamine for over 25 years, it was with great interest that I learned about the Manitoba government’s recent proposal to advance Bill 48, the Protective Detention and Care of Intoxicated Persons Act.

I have concerns that this proposed law shows a lack of understanding of the options presently available for the detainment and assessment of citizens intoxicated on substances other than alcohol, and the important differences between alcohol intoxication and methamphetamine or opioid intoxication.

Firstly, Housing, Homeless and Addictions Minister Bernadette Smith states legislation now allows for a 24-hour involuntary holds for people intoxicated by alcohol, but for those intoxicated by other substances, the choice is to either criminalize them or take them to a hospital where they are often waiting “… 10 hours plus with police.”

Both of these statements are either false or represent worst-case scenarios.

The present Intoxicated Persons Detention Act (1987) does not specify alcohol. It allows for police to take into custody a person in a public place who is intoxicated, and take them to a detox centre where they may be held for up to 24 hours. Although this act is primarily used for alcohol-intoxicated persons, it is not limited to alcohol intoxication.

From the police officer’s viewpoint, alcohol intoxication is relatively easy to assess. Alcohol has a distinctive odour on the breath and intoxication with alcohol is accompanied by characteristic physical signs including slurred speech, a stumbling gait and impaired short-term memory. Most officers are trained in administering field sobriety tests, which is an objective test for alcohol intoxication. Alcohol is also metabolized rather consistently across the population, and in most cases, sobriety and a return to normal behaviour occurs within 24 hours, and the detainee can be safely discharged.

Generally, detainees under this act will be provided with a list of community resources for addiction services, although there is no compulsory followup.

Methamphetamine intoxication follows a much more unpredictable course than alcohol intoxication. Classically, persons intoxicated on methamphetamine come to the attention of the public or police when they are causing public disturbances including screaming or frightening and disturbing local citizens and shopkeepers.

Their actions and behaviours may be due to intoxication with stimulants such as methamphetamine, but also may be due to other conditions such as a primary psychotic or bipolar disorder, (mania) or a combination of both a primary mental health disorder and intoxication. Even for a veteran emergency physician or peace officer, it is impossible to determine the cause of the disturbed behaviour.

Even if someone tests positive for the presence of methamphetamine, (such as saliva or urine tests) testing for methamphetamine can only confirm the presence or absence of methamphetamine and is not correlated with the degree of disturbance observed. A positive test only shows that the person has likely used sometime in the last 48 hours, and does not prove that the disturbed behaviour is solely due to methamphetamine use.

Additionally, if someone is so intoxicated by methamphetamine that they draw public and police attention, they are also at risk for serious medical complications including seizures, arrhythmias or cardiac arrest, and require assessment by a trained physician in an emergency room or possibly an advanced care paramedic in the field.

Bill 48 permits a police officer to take a person suspected of being high on methamphetamine in public directly to a “protective care centre” or “detention.”

There is no requirement that a medical or psychiatric assessment be done for at least 24 hours after initial detainment. Bypassing these assessments places the intoxicated individual at risk of serious medical complications including death.

Also, the decision that the intoxicated person’s behaviour is solely due to substances misses the opportunity to have them assessed by a psychiatrist and set up with recommended followup care.

Smith, along with Winnipeg Police Chief Gene Bowers, states patients intoxicated by suspected methamphetamine use can often wait up to 10 hours with police for an assessment in a hospital emergency ward and “… handcuffed to a chair or bed for their own safety.”

While I’m in agreement that it would be much better use of the officers’ time and abilities to be actively attending to their duties and protecting our neighbourhoods, this should not be at the cost of detaining disturbed individuals presumed to be intoxicated on substances without proper medical assessments and care.

In fact, once at the hospital, police can transfer the custody of a presumably intoxicated person to another qualified person, (defined in the Mental Health Act) which can be a hospital security guard with additional training or an institutional safety officer, a position that was announced with much fanfare, in April 2024.

The comment that intoxicated persons are “often handcuffed to a chair or bed for their own safety and the safety of others” is dramatic, but a relatively rare event in clinical practice. Emergency rooms have equipment to restrain agitated patients that are less likely to cause harm than police issued handcuffs. Emergency room staff are also able to assess the need for sedating medications, and then monitor for any adverse side effects.

Admittedly, being brought to a hospital emergency room (usually the Health Sciences Centre in Winnipeg) when intoxicated and agitated can be a very unpleasant event. The option presented with this bill is to be brought to a “protective care centre” which is similar to the present Intoxicated Persons Detention Unit.

This “centre” will often be a chaotic and noisy environment and may frequently result in an agitated patient being locked in a containment area with limited amenities.

One advantage forwarded by the proponents of Bill 48, is that the 72-hour period of a detention will allow time for the (presumed) methamphetamine psychosis to clear, and give time to connect with followup supports and programs. I fail to see how this is an improvement over the present Mental Health Act in Manitoba (proclaimed in 1998, and overdue for a review and revision).

Under the present Mental Health Act, a citizen presenting with a mental health disorder, and assessed to be at risk of harming themselves or others, or at risk for substantial deterioration, can be detained for up to 72 hours in a psychiatric facility.

The fact that the symptoms, including psychosis, may be substance-induced does not negate the use of the Mental Health Act.

In practice, if a disturbed individual is brought to the emergency room by the police and drug use is suspected as a cause, they are often provided with sedating medication. Should the symptoms not resolve within approximately 12 hours, psychiatry will be consulted to assess for admission.

I would argue that psychiatric wards are the best equipped facilities to assess patients with psychosis, (whether primary or substance-induced) and are best able to arrange follow up care for both addictions and mental health concerns as efficiently as possible.

In summary, the proposed Bill 48 is redundant in its aim to provide protective detention and care of intoxicated persons. There is legislation, facilities and trained health care professionals in place already for involuntary detention of intoxicated (by any substance) citizens that present a danger to themselves or others.

In fact, this bill may lead to a lower standard of care to some of the most vulnerable citizens in Winnipeg, and an increase in critical events due to a lack of medical and psychiatric assessments.

If additional services are required, increased psychiatric inpatient beds for assessment and treatment of patients with substance induced psychosis and increased availability and access to longer term substance abuse facilities should be the first priorities.

Dr. Jim Simm is the former chief provincial psychiatrist of Manitoba and has specialized in the assessment and treatment of addictions and psychosis for over 25 years.